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Deep Learning Technology: Sebastian Arnold, Betty van Aken, Paul Grundmann, Felix A. Gers and Alexander Löser. Learning Contextualized Document Representations for Healthcare Answer Retrieval. The Web Conference 2020 (WWW'20)
Funded by The Federal Ministry for Economic Affairs and Energy; Grant: 01MD19013D, Smart-MD Project, Digital Technologies
Medical conditions associated with an increased risk of PTSD include cancer, heart attack, and stroke. Intensive-care unit (ICU) hospitalization is also a risk factor for PTSD. Some women experience PTSD from their experiences related to breast cancer and mastectomy.
Women who experience miscarriage are at risk of PTSD. Those who experience subsequent miscarriages have an increased risk of PTSD compared to those experiencing only one. PTSD can also occur after childbirth and the risk increases if a woman has experienced trauma prior to the pregnancy. Prevalence of PTSD following normal childbirth (that is, excluding stillbirth or major complications) is estimated to be between 2.8 and 5.6% at 6 weeks postpartum, with rates dropping to 1.5% at 6 months postpartum. Symptoms of PTSD are common following childbirth, with prevalence of 24-30.1% at 6 weeks, dropping to 13.6% at 6 months. Emergency childbirth is also associated with PTSD. Some women experience PTSD from their experiences related to breast cancer and mastectomy.
Various factors have been found to be more associated with a diagnosis of AD than other axis I disorders, including:
- younger age
- more identified psychosocial and environmental problems
- increased suicidal behaviour, more likely to be rated as improved by the time of discharge from mental healthcare
- less frequent previous psychiatric history
- shorter length of treatment
Those exposed to repeated trauma are at greater risk, even if that trauma is in the distant past. Age can be a factor due to young children having fewer coping resources; children are also less likely to assess the consequences of a potential stressor.
A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. The stressors that cause adjustment disorders may be grossly traumatic or relatively minor, like loss of a girlfriend/boyfriend, a poor report card, or moving to a new neighborhood. It is thought that the more chronic or recurrent the stressor, the more likely it is to produce a disorder. The objective nature of the stressor is of secondary importance. Stressors' most crucial link to their pathogenic potential is their perception by the patient as stressful. The presence of a causal stressor is essential before a diagnosis of adjustment disorder can be made.
There are certain stressors that are more common in different age groups:
Adulthood:
- Marital conflict
- Financial conflict
- Health issues with Oneself/Partner or Dependent children
- Personal tragedy (Death/personal loss)
- Loss of job or unstable employment conditions (e.g. Corporate takeover/redundancy)
Adolescence and childhood:
- Family conflict/parental separation
- School problems/changing schools
- Sexuality issues
- Death/illness/trauma in the family
In a study conducted from 1990 to 1994 on 89 psychiatric outpatient adolescents, 25% had attempted suicide in which 37.5% had misused alcohol, 87.5% displayed aggressive behaviour, 12.5% had learning difficulties, and 87.5% had anxiety symptoms.
Traumatic grief or complicated mourning are conditions where both trauma and grief coincide. There are conceptual links between trauma and bereavement since loss of a loved one is inherently traumatic. If a traumatic event was life-threatening, but did not result in death, then it is more likely that the survivor will experience post-traumatic stress symptoms. If a person dies, and the survivor was close to the person who died, then it is more likely that symptoms of grief will also develop. When the death is of a loved one, and was sudden or violent, then both symptoms often coincide. This is likely in children exposed to community violence.
For C-PTSD to manifest, the violence would occur under conditions of captivity, loss of control and disempowerment, coinciding with the death of a friend or loved one in life-threatening circumstances. This again is most likely for children and stepchildren who experience prolonged domestic or chronic community violence that ultimately results in the death of friends and loved ones. The phenomenon of the increased risk of violence and death of stepchildren is referred to as the Cinderella effect.
According to the DSM IV-TR, the development of the emotional or behavioral symptoms of this diagnosis have to occur within three months of the onset of the identifiable stressor(s). Some emotional signs of adjustment disorder are:
However, the stress-related disturbance does not only exist as an exacerbation of a pre-existing axis I or axis II disorder and cannot be diagnostic as axis 1 disorder.
Suicidal behavior is prominent among people with AD of all ages, and up to one-fifth of adolescent suicide victims may have an adjustment disorder. Bronish and Hecht (1989) found that 70% of a series of patients with AD attempted suicide immediately before their index admission and they remitted faster than a comparison group with major depression. Asnis et al. (1993) found that AD patients report persistent ideation or suicide attempts less frequently than those diagnosed with major depression. According to a study on 82 AD patients at a clinic, Bolu et al. (2012) found that 22 (26.8%) of these patients were admitted due to suicide attempt, consistent with previous findings. In addition, it was found that 15 of these 22 patients chose suicide methods that involved high chances of being saved. Henriksson et al. (2005) states statistically that the stressors are of one-half related to parental issues and one-third in peer issues.
Posttraumatic embitterment disorder (PTED) is a proposed disorder modeled after posttraumatic stress disorder. Some psychiatrists are proposing this as a mental disorder because they believe that there are people who have become so bitter, they can barely function. PTED patients do not fit the formal criteria for PTSD and can be clinically distinguished from it, prompting the description of a new and separate disorder.
German psychiatrist Michael Linden, who has conducted research on the proposed disorder, describes its effect on people: "They feel the world has treated them unfairly. It's one step more complex than anger. They're angry plus helpless." He says that people with the disorder are almost treatment resistant and that; "These people usually don't come to treatment because 'the world has to change, not me. He believes that 1 to 2 percent of people are affected at any given time, and explains that, although sufferers of the disorder tend to have a desire for vengeance, "...Revenge is not a treatment."
PTED so far has no official status and is not listed in the DSM-IV-TR or ICD-10-CM.
PTSD has significant arousal and other effects on physiological, endocrine, HPA axis, brain centers, and neurological systems. These have been the bases of treatments well known and studied for decades via both theoretical and practical descriptions of illness, rationales of treatment modalities, and mechanisms of therapeutic actions.
PTED may arouse or influence PTSD-affected systems differently or arouse different systems. Thus PTED, although modeled on PTSD, may differ to various degrees and in various ways.
There is no published work at this time on different underlying neurological, endocrinology, and physiological changes in PTED patients as an analog to PTSD.
Complex post-traumatic stress disorder (C-PTSD; also known as complex trauma disorder) is a psychological disorder thought to occur as a result of repetitive, prolonged trauma involving harm or abandonment by a caregiver or other interpersonal relationships with an uneven power dynamic. C-PTSD is associated with sexual, emotional or physical abuse or neglect in childhood, intimate partner violence, victims of kidnapping and hostage situations, indentured servants, victims of slavery, sweatshop workers, prisoners of war, victims of bullying, concentration camp survivors, and defectors of cults or cult-like organizations. Situations involving captivity/entrapment (a situation lacking a viable escape route for the victim or a perception of such) can lead to C-PTSD-like symptoms, which include prolonged feelings of terror, worthlessness, helplessness, and deformation of one's identity and sense of self.
Some researchers argue that C-PTSD is distinct from, but similar to PTSD, somatization disorder, dissociative identity disorder, and borderline personality disorder, with the main distinction being that it distorts a person's core identity, especially when prolonged trauma occurs during childhood development . It was first described in 1992 by Judith Herman in her book "Trauma & Recovery" and an accompanying article. Though peer-reviewed journals have published papers on C-PTSD, the category is not yet adopted by either the American Psychiatric Association's (APA) "Diagnostic and Statistical Manual of Mental Disorders", 5th Edition (DSM-5), or in the World Health Organization's (WHO) "International Statistical Classification of Diseases and Related Health Problems", 10th Edition (ICD-10). However, it is proposed for the ICD-11, to be finalized in 2018.
Emotional dysregulation (ED) is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response.
Possible manifestations of emotional dysregulation include angry outbursts or behavior outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. These variations usually occur in seconds to minutes or hours. Emotional dysregulation can lead to behavioral problems and can interfere with a person's social interactions and relationships at home, in school, or at place of employment.
Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as reactive attachment disorder. Emotional dysregulation may present in people with psychiatric disorders such as attention deficit hyperactivity disorder, bipolar disorder, borderline personality disorder, narcissistic personality disorder, and complex post-traumatic stress disorder. ED is also found among those with autism spectrum disorders. In such cases as borderline personality disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain.
Individual differences in women's estrogen cycles may be related to the expression of BPD symptoms in female patients. A 2003 study found that women's BPD symptoms were predicted by changes in estrogen levels throughout their menstrual cycles, an effect that remained significant when the results were controlled for a general increase in negative affect.
Rape trauma syndrome (RTS) is the psychological trauma experienced by a rape victim that includes disruptions to normal physical, emotional, cognitive, and interpersonal behavior. The theory was first described by psychiatrist Ann Wolbert Burgess and sociologist Lynda Lytle Holmstrom in 1974.
RTS is a cluster of psychological and physical signs, symptoms and reactions common to most rape victims immediately following and for months or years after a rape. While most research into RTS has focused on female victims, sexually abused males (whether by male or female perpetrators) also exhibit RTS symptoms. RTS paved the way for consideration of complex post-traumatic stress disorder, which can more accurately describe the consequences of serious, protracted trauma than posttraumatic stress disorder alone. The symptoms of RTS and post-traumatic stress syndrome overlap. As might be expected, a person who has been raped will generally experience high levels of distress immediately afterward. These feelings may subside over time for some people; however, individually each syndrome can have long devastating effects on rape victims and some victims will continue to experience some form of psychological distress for months or years. It has also been found that rape survivors are at high risk for developing substance use disorders, major depression, generalized anxiety disorder, obsessive-compulsive disorder, and eating disorders.
RTS identifies three stages of psychological trauma a rape survivor goes through: the acute stage, the outer adjustment stage, and the renormalization stage.
Vicarious trauma affects workers being 'witnesses' to their clients' trauma. It is more likely to occur in situations where trauma related work is the norm rather than the exception. Listening with empathy to the clients generates feeling, and 'seeing oneself' in clients' trauma may compound the risk for developing trauma symptoms. May also result if we are witness to situations that happen in the course of our work (e.g. violence in the workplace, reviewing violent video tapes, etc.). Risk increases with exposure and with the absence of seeking protective factors and pre-preparation of preventive strategies.
Early experiences with caregivers can lead to differences in emotional regulation. The responsiveness of a caregiver to an infant's signals can help an infant regulate their emotional systems. Caregiver interaction styles that overwhelm a child or that are unpredictable may undermine emotional regulation development. Effective strategies involve working with a child to support developing self-control such as modeling a desired behavior rather than demanding it.
The richness of environment that a child is exposed to helps development of emotional regulation. An environment must provide appropriate levels of freedom and constraint. The environment must allow opportunities for a child to practice self-regulation. An environment with opportunities to practice social skills without over-stimulation or excessive frustration helps a child develop self-regulation skills.
The lifetime prevalence of dissociative disorders varies from 10% in the general population to 46% in psychiatric inpatients. Diagnosis can be made with the help of structured interviews such as the Dissociative Disorders Interview Schedule (DDIS) and the Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D), or with the Dissociative Experiences Scale (DES) which is a self-assessment questionnaire. Some diagnostic tests have also been adapted and/or developed for use with children and adolescents such as the Children's Version of the Response Evaluation Measure (REM-Y-71), Child Interview for Subjective Dissociative Experiences, Child Dissociative Checklist (CDC), Child Behavior Checklist (CBCL) Dissociation Subscale, and the Trauma Symptom Checklist for Children Dissociation Subscale.
There are problems with classification, diagnosis and therapeutic strategies of dissociative and conversion disorders which can be understood by the historic context of hysteria. Even current systems used to diagnose DD such as the DSM-IV and ICD-10 differ in the way the classification is determined. In most cases mental health professionals are still hesitant to diagnose patients with Dissociative Disorder, because before they are considered to be diagnosed with Dissociative Disorder these patients have more than likely been diagnosed with major depression, anxiety disorder, and most often post-traumatic disorder.
An important concern in the diagnosis of dissociative disorders is the possibility that the patient may be feigning symptoms in order to escape negative consequences. Young criminal offenders report much higher levels of dissociative disorders, such as amnesia. In one study it was found that 1% of young offenders reported complete amnesia for a violent crime, while 19% claimed partial amnesia. There have also been incidences in which people with dissociative identity disorder provide conflicting testimonies in court, depending on the personality that is present.
PBA is one of the most frequently reported post-stroke behavioral syndromes, with a range of reported prevalence rates from 28% to 52%. The higher prevalence rates tend to be reported in stroke patients who are older and/or who have a history of prior stroke. The relationship between post-stroke depression and PBA is complicated, because the depressive syndrome also occurs with high frequency in stroke survivors. Post-stroke patients with PBA are more depressed than poststroke patients without PBA, and the presence of a depressive syndrome may exacerbate the weeping side of PBA symptoms.
There is a strong correlation between child abuse, especially child sexual abuse, and development of BPD. Many individuals with BPD report a history of abuse and neglect as young children, but causation is still debated. Patients with BPD have been found to be significantly more likely to report having been verbally, emotionally, physically, or sexually abused by caregivers of either gender. They also report a high incidence of incest and loss of caregivers in early childhood. Individuals with BPD were also likely to report having caregivers of both sexes deny the validity of their thoughts and feelings. Caregivers were also reported to have failed to provide needed protection and to have neglected their child's physical care. Parents of both sexes were typically reported to have withdrawn from the child emotionally and to have treated the child inconsistently. Additionally, women with BPD who reported a previous history of neglect by a female caregiver and abuse by a male caregiver were significantly more likely to experience sexual abuse by a non-caregiver.
It has been suggested that children who experience chronic early maltreatment and attachment difficulties may go on to develop borderline personality disorder. Writing in the psychoanalytic tradition, Otto Kernberg argues that a child's failure to achieve the developmental task of and failure to overcome splitting might increase the risk of developing a borderline personality. A child's inability to tolerate delayed gratification at age four does not predict later development of BPD.
One study of 301 consecutive cases in a clinic setting reported a 5% prevalence. PBA occurred in patients with more severe head injury, and coincided with other neurological features suggestive of pseudobulbar palsy.
The Brain Injury Association of America (BIAA) indicates that approximately 80% of survey respondents experience symptoms of PBA. Results from a recent investigation estimate the prevalence of PBA associated with traumatic brain injury to exceed more than 55% of survivors.
A 2007 study found that 78% of a clinical sample of OCD patients had intrusive images. Most people who suffer from intrusive thoughts have not identified themselves as having OCD, because they may not have what they believe to be classic symptoms of OCD, such as handwashing. Yet, epidemiological studies suggest that intrusive thoughts are the most common kind of OCD worldwide; if people in the United States with intrusive thoughts gathered, they would form the fourth-largest city in the US, following New York City, Los Angeles, and Chicago.
The prevalence of OCD in every culture studied is at least 2% of the population, and the majority of those have obsessions, or bad thoughts, only; this results in a conservative estimate of more than 2 million sufferers in the United States alone (as of 2000). One author estimates that one in 50 adults have OCD and about 10–20% of these have sexual obsessions. A recent study found that 25% of 293 patients with a primary diagnosis of OCD had a history of sexual obsessions.
All psychological traumas originate from stress, a physiological response to an unpleasant stimulus. Long term stress increases the risk of poor mental health and mental disorders, which can be attributed to secretion of glucocorticoids for a long period of time. Such prolonged exposure causes many physiological dysfunctions such as the suppression of the immune system and increase in blood pressure. Not only does it affect the body physiologically, but a morphological change in the hippocampus also takes place. Studies showed that extreme stress early in life can disrupt normal development of hippocampus and impact its functions in adulthood. Studies surely show a correlation between the size of hippocampus and one's susceptibility to stress disorders. In times of war, psychological trauma has been known as shell shock or combat stress reaction. Psychological trauma may cause an acute stress reaction which may lead to posttraumatic stress disorder (PTSD). PTSD emerged as the label for this condition after the Vietnam War in which many veterans returned to their respective countries demoralized, and sometimes, addicted to psychoactive substances. The symptoms of PTSD must persist for at least a month for diagnosis. The main symptoms of PTSD consist of four main categories: Trauma (i.e. intense fear), reliving (i.e. flashbacks), avoidance behavior (i.e. emotional numbing), and hypervigilance (i.e. irritability). Research shows that about 60% of the US population reported as having experienced at least one traumatic symptom in their lives but only a small proportion actually develops PTSD. There is a correlation between the risk of PTSD and whether or not the act was inflicted deliberately by the offender. Psychological trauma is treated with therapy and, if indicated, psychotropic medications.
The term "continuous post traumatic stress disorder" (CTSD) was introduced into the trauma literature by Gill Straker (1987). It was originally used by South African clinicians to describe the effects of exposure to frequent, high levels of violence usually associated with civil conflict and political repression. The term is also applicable to the effects of exposure to contexts in which gang violence and crime are endemic as well as to the effects of ongoing exposure to life threats in high-risk occupations such as police, fire and emergency services.
As one of the processes of treatment, confrontation with their sources of trauma plays a crucial role. While critical incident debriefing people immediately after an event has not been shown to reduce incidence of PTSD, coming alongside people experiencing trauma in a supportive way has become standard practice.
There are several theoretical perspectives on trauma response, including cognitive, biological, and psychobiological. While the theories are PTSD-specific, they are still useful in understanding ASD, as both share many symptoms.
Acute stress disorder (abbreviated ASD, and not to be confused with autism spectrum disorder) is the result of a traumatic event in which the person experiences or witnesses an event that causes the victim/witness to experience extreme, disturbing, or unexpected fear, stress, or pain, and that involves or threatens serious injury, perceived serious injury, or death to themselves or someone else. A study of rescue personnel after exposure to a traumatic event showed no gender difference in acute stress reaction. Acute stress reaction is a variation of post-traumatic stress disorder (PTSD).
A recent study found that a "single" stressful event may cause long-term consequences in the brain. This result calls the traditional distinction between the effects of acute vs chronic stress into question.
A wide range of factors have been identified as being predictive of PCS, including low socioeconomic status, previous mTBI, a serious associated injury, headaches, an ongoing court case, and female gender. Being older than 40 and being female have also been identified as being predictive of a diagnosis of PCS, and women tend to report more severe symptoms. In addition, the development of PCS can be predicted by having a history of alcohol abuse, low cognitive abilities before the injury, a personality disorder, or a medical illness not related to the injury. PCS is also more prevalent in people with a history of psychiatric conditions such as clinical depression or anxiety before the injury.
Mild brain injury-related factors that increase the risk for persisting post-concussion symptoms include an injury associated with acute headache, dizziness, or nausea; an acute Glasgow Coma Score of 13 or 14; and suffering another head injury before recovering from the first. The risk for developing PCS also appears to be increased in people who have traumatic memories of the injury or expect to be disabled by the injury.
Dissociative disorders (DD) are widely believed to have roots in traumatic childhood experience (abuse or loss), but symptomology often goes unrecognized or is misdiagnosed in children and adolescents. There are several reasons why recognizing symptoms of dissociation in children is challenging: it may be difficult for children to describe their internal experiences; caregivers may miss signals or attempt to conceal their own abusive or neglectful behaviors; symptoms can be subtle or fleeting; disturbances of memory, mood, or concentration associated with dissociation may be misinterpreted as symptoms of other disorders.
In addition to developing diagnostic tests for children and adolescents (see above), a number of approaches have been developed to improve recognition and understanding of dissociation in children. Recent research has focused on clarifying the neurological basis of symptoms associated with dissociation by studying neurochemical, functional and structural brain abnormalities that can result from childhood trauma. Others in the field have argued that recognizing disorganized attachment (DA) in children can help alert clinicians to the possibility of dissociative disorders.
Clinicians and researchers also stress the importance of using a developmental model to understand both symptoms and the future course of DDs. In other words, symptoms of dissociation may manifest differently at different stages of child and adolescent development and individuals may be more or less susceptible to developing dissociative symptoms at different ages. Further research into the manifestation of dissociative symptoms and vulnerability throughout development is needed. Related to this developmental approach, more research is required to establish whether a young patient’s recovery will remain stable over time.
This disorder may resolve itself with time or may develop into a more severe disorder such as PTSD. However, results of Creamer, O'Donnell, and Pattison's (2004) study of 363 patients suggests that a diagnosis of acute stress disorder had only limited predictive validity for PTSD. Creamer et al. did find that re-experiences of the traumatic event and arousal were better predictors of PTSD. Early pharmacotherapy may prevent the development of posttraumtic symptoms.
Studies have been conducted to assess the efficacy of counselling and psychotherapy for people with ASD. Cognitive behavioral therapy which included exposure and cognitive restructuring was found to be effective in preventing PTSD in patients diagnosed with ASD with clinically significant results at 6 months follow-up. A combination of relaxation, cognitive restructuring, imaginal exposure, and in vivo exposure was superior to supportive counseling. Mindfulness based stress reduction programs also appear to be effective for stress management.
In a wilderness context where counseling, psychotherapy, and cognitive behavioral therapy is unlikely to be available, the treatment for acute stress reaction is very similar for the treatment of cardiogenic shock, vascular shock, and hypovolemic shock; that is, allowing the patient to lie down, providing reassurance, and removing the stimulus for the occurrence of the reaction. In traditional shock cases, this is generally the relieving of pain from injuries or the stopping of blood loss. In an acute stress reaction, this may be pulling a rescuer away from the emergency to calm down, or blocking the sight of an injured friend from a patient.
Peacekeeping provides its own stresses because its emphasis on rules of engagement contains the roles for which soldiers are trained. Causes include witnessing or experiencing the following:
- Constant tension and threat of conflict.
- Threat of land mines and booby traps.
- Close contact with severely injured and dead people.
- Deliberate maltreatment and atrocities, possibly involving civilians.
- Cultural issues, e.g. male dominant attitudes towards women in different cultures.
- Separation and home issues.
- Risk of disease including HIV.
- Threat of exposure to toxic agents.
- Mission problems.
- Return to service.